The following images demonstrate the temporary depigmentation and atrophy effects of Kenalog injected in the hand and wrist. The follow-up image is 6 months later.
Steroid Skin Blanching
3 Phalanx IM screws
History: 39 year old gentleman came to the office after a steel beam fell on his hand, crushing his index, middle, and ring fingers. He had fractures of the proximal phalanx to all three fingers and limited motion, swelling, and pain.
Diagnosis: P1 fractures of index, middle, ring fingers
Treatment: Index and Middle fingers intramedullary screw, Ring finger pinning
Outcome: At 2.5 months he had nearly full motion and no pain. The index and middle fingers were significantly better than the ring finger in regards to motion.
Table Saw Skin Graft
History: 63 year old gentleman sustained a table saw injury to his right index finger. This included a deep skin injury with full thickness loss but did not seem to involved the tendons, nerves, or vessels.
Diagnosis: Right index full thickness loss
Treatment: Full thickness skin graft to digit
Outcome: Despite early loss of part of the graft, the entire wound quickly granulated in resulting in full coverage, full motion, and return to full activities.
PIP Joint ORIF
History: A 19 year old gentleman injured his middle finger joint while punching a wall. He presented to my office with an inability to flex and extend his middle finger and with pain and swelling.
Diagnosis: Middle finger PIP joint intra-articular fracture with subluxation, moderately improved with traction
Treatment: Middle phalanx open reduction, internal fixation with screws
Outcome: He did exceptionally well. At his first post-op visit he could nearly make a full fist and within 2 months he had nearly full motion without any pain.
Deep Palm Infection
History: 71 year old female presented to the hospital about 2 weeks after a fall with increasing pain and swelling in her hand and palm. She had a history of psoriatic arthritis for which she took methotrexate and infliximab. Her presentation was very concerning for a deep infection with a WBC of 41,000, lactate of 2.6, and a CT scan in the emergency department showing a deep abscess around the median nerve.
Diagnosis: Left palm deep space infection in the setting of immunosuppresion
Treatment: Urgent I&D of the deep space through an extended carpal tunnel incision, before and after photos
Outcome: She made a rapid recovery with IV antibiotics. Ultimately she was able to regain nearly all of her function and return to her usual daily routine.
Flexor Tenosynovitis
History: A 55 year old female with diabetes presented to my office with severe pain and swelling in her middle finger a few days after burning the tip of her finger. This was initially treated with antibiotics for cellulitis however she rapidly progressed to flexor tenosynovitis based on the appearance and was taken to the operating room for urgent exploration, irrigation, and debridement of the tendon sheath.
Diagnosis: Right middle finger flexor tenosynovitis
Treatment: Flexor sheath I&D followed by daily soaks
Outcome: Over weeks to months she healed the incision. The flexor tendons required excision and she had limited flexion of the finger, but it remains infection-free. She currently has very limited feeling in the finger.
Segmental Galeazzi
History: 24 year old gentleman presented to the hospital after crashing his motorcycle. He had obvious deformities to his right forearm and wrist. I evaluated him and recommended surgery for his complex radial shaft and DRUJ injuries. Intra-operatively he was found to have multiple shaft fractures, further complicating the surgery.
Diagnosis: Right wrist and forearm Galeazzi fracture
Treatment: Intra-operative findings necessitated and combination of pins and plate extensions in addition to standard volar plating and screws to capture multiple fracture components. The sequence of fixation is shown here.
Outcome: He did very well in the early post-operative period, making improvements in his wrist motion and forearm supination. By 1 month he had already regained 30% of wrist motion and 50% of forearm supination. He had very little pain and was slowly returning to activity.
Open Galeazzi – Franko
History: 58 year old male was hit by a vehicle and presented to the hospital with obvious open deformities of his right forearm and wrist. He was diagnosed with an open radial shaft fracture and instability of the distal radioulnar joint.
Diagnosis: Right open Galeazzi fracture
Treatment: Open reduction, internal fixation of the radius with a combination of plates and screws
Outcome: By 3 months after surgery he was healing exceptionally well. He had very good wrist motion of greater than 70 degree arc, near full supination and pronation, and no pain.
